DNS overruled MD?!

[JBMmom]

We have a resident in her 80's, has a history of rapidly deteriorating when ill. Wednesday she started running a temp in the low 100's, some SOB, labs had been drawn and show that she's septic. She's still a full code, and has good QOL, just got sick (not that it's relevant to this treatment, just FYI). Anyway, on Wed, the medical director wanted her sent out- the DNS refused to send her. I heard yesterday that it was because she not did want the census to drop. WHAT?! I came on second shift yesterday and she had a temp of 101, respirations 24, breathing heavy and sats still in the high 80s on 2L. Her assigned nurse was not comfortable and decided she needed to be sent. The resident herself finally said she should go to the hospital. When the supervisor called the DNS to let her know, apparently she was ticked off. Asked whether the resident was "really" in distress or did Dr. --- just want her sent out. Really? Now you're questioning your nurse's assessment/integrity, and even if the MD did "just want her sent out"- isn't it ultimately his call? While I understand in LTC we run by the corporate rules, it was just disheartening to see it in action.

[mlbluvr]

Of course you're right, but of course it isn't going to happen. Aside from the constant cuts and Republican threats to Medicaid, there's also a growing push to divert Medicaid funds more to HCBS, and away from SNFs. The MDS 3.0 is actually part of that plot. Several states claim they have transferred 5% more money to home care rather than SNFs, already, since MDS 3.0 came to town- that's impressive, and reflects the explosion in home health care agencies, and hospices- many of which are total scams. As this continues forward, the people left in the SNFs will be more sick, require more care and more equipment, more resources of every type, all the while the reimbursement heads the other direction. For the time being, if you're a nursing home nurse with the beautifully elaborated conditions the previous posted listed, you either gotta laugh, or you'll CRY.

[ClearBlueOctoberSky]

Huh. I guess I'm lucky enough to work in a facility that has a very supportive Management Team, NHA, and Medical Director.

If you don't feel like you are getting enough support, then that is an issue that needs brought up.

With the new legislature, LTC, I believe is going to start to not only take higher acuity patients, but also be in a position where they are going to have to treat in house when applicable, and not dump to the ER's.

[mlbluvr]

SNFs are certainly next targeted for sending people to the hospital, when chart reviews indicate that the treatment the hospital provided was in fact fully available in the SNF, for sure. That's on the close horizon. And, CBOS? Wow- what a lovely image your name conjures up. Just ... beautiful~

[ClearBlueOctoberSky]

Aww, well thanks, mlbluvr.

[wyogypsy, RN]

I quit that facility. My license was on the line more often than not, and the workload was out of my control. The company is well known for having as low of staff as possible. Part of the problem could have been fixed by dividing the Medicare patients between different halls, but the Area Manager, who was not a nurse, wanted them all in one hall. I don't mind working hard, and I love LTC, but that assignment definitely got the best of me.

[JBMmom, MSN, NP]

Thanks to everyone for the balanced feedback. I wasn't on-line for a few days, so I didn't update. The resident in question did end up in an ICU at the local hospital-in septic shock. As of my most recent shift last week she had not yet returned to our facility. I intend to ask the DNS about this directly, because my "didn't want to send out due to census" was a second-hand comment, so I want to get a direct answer/explanation. Not because I'm owed it, but I don't want to be caught in a situation where mis-information is influencing my opinion of someone. And because if a resident on my wing starts exhibiting signs of distress that I don't feel qualified to handle, I'd like to know that the DNS would support my decisions, or provide the appropriate resources/education to get me through the situation.